33.08 Intraoperative Autofluorescence Parathyroid Localization in MEN1 Patients

Posted on January 31, 2019

M. H. Squires1, R. Jarvis1, L. A. Shirley1, J. E. Phay1  1Ohio State University,Division Of Surgical Oncology,Columbus, OH, USA

Introduction:  Intrinsic near-infrared (NIR) autofluorescence (AF) of the parathyroid gland enables intraoperative gland identification and localization, without the need for contrast agent injection. Whether real-time AF imaging is useful in patients with multiple endocrine neoplasia type 1 (MEN1) and primary hyperparathyroidism, however, is unknown.

Methods:  Patients undergoing surgery for primary hyperparathyroidism by two experienced endocrine surgeons were enrolled in a prospective clinical trial. Intraoperative imaging was performed with a handheld NIR AF device and images were captured for analysis. Representative areas of greatest AF from the parathyroid, thyroid, and adjacent soft tissue were quantified by Image J software and reported as mean values with standard deviation. Rates of false negative (lack of significant parathyroid gland AF compared to background AF, defined as parathyroid AF:background AF ratio <1.10) and false positive AF (aberrant AF of non-parathyroid tissue confirmed by pathology) were analyzed.

Results: Seventy-one consecutive patients with primary hyperparathyroidism underwent parathyroidectomy from 2017-2018. These included 6 patients with MEN1 diagnosed either genetically or clinically and 65 non-MEN1 patients. No significant differences in serum preoperative parathyroid hormone level or parathyroid gland size or weight on pathology were observed between the two cohorts (all p>0.2).

 

The mean absolute value of in situ parathyroid AF was significantly lower for MEN1 patients than non-MEN1 patients (55.2 +/- 9.5 vs. 76.7 +/- 21.4; p=0.001), as was the ratio of parathyroid to background AF (0.99 vs. 1.64; p=0.005). Three of six MEN1 patients (50%) had falsely negative non-fluorescent parathyroid adenomas (Fig D) versus a false negative rate of 12% (8 of 65) among non-MEN1 patients. The fibroadipose and lymphatic tissue of MEN1 patients exhibited greater background AF (Fig F), leading to high false positive rates (5 of 6 patients; 83%) versus only 3 of 65 (5%) false positive AF non-parathyroid specimens among non-MEN1 patients. 

Conclusion: Intraoperative identification of parathyroids using their intrinsic autofluorescence by real-time NIR imaging appears to have utility in patients with primary hyperparathyroidism. In this cohort of MEN1 patients, decreased parathyroid AF and increased background AF of non-parathyroid tissue led to high rates of false negative and false positive fluorescence, potentially limiting the utility of this intraoperative imaging adjunct in this specific subset of patients.
 

33.07 Gender Disparities in Bone Density Testing of Patients with Hyperparathyroidism: A Bias Against Men

Posted on January 31, 2019

P. H. Dedhia1, A. D. McDow1, K. L. Long1, S. L. Pitt1, D. F. Schneider1, R. S. Sippel1  1University Of Wisconsin,Division Of Endocrine Surgery,Madison, WI, USA

Introduction:  Primary Hyperparathyroidism can lead to osteoporosis.  Guidelines recommend that all patients with primary hyperparathyroidism should undergo a DEXA scan to evaluate for the presence of bone disease.  While osteoporosis is more common in women, we sought to determine if there were gender differences in the presence or the evaluation of bone disease in female and male patients with primary hyperparathyroidism.

Methods:  This is a retrospective review of a prospective surgical database of 3608 patients with primary hyperparathyroidism who underwent surgical exploration between 2000 and 2018 at a single institution. Clinical characteristics, DEXA scan evaluation, mean t-scores, and the presence of osteopenia or osteoporosis were studied.

Results: Of the 3608 patients with hyperparathyroidism who underwent surgical exploration, 78% (n=2818) were female and 29% (n=790) were male. Female patients were significantly more likely to have a history of either fractures or osteopenia or osteoporosis compared to the male patients (65% vs. 15%, p<0.0001). Furthermore, female patients were also significantly more likely to undergo a DEXA scan during their pre-operative evaluation than male patients, 49% versus 28% (p<0.00001).

In looking at only those patients who underwent a DEXA scan, 86% of women versus 77% of men had osteopenia or osteoporosis as indicated by a t-score of <1.0 (p=0.0008). A diagnosis of osteoporosis was present in 32% of women versus 22% of men (p=0.0035). Mean t-score was -1.71 for women compared to -1.92 for men (p=0.07).  Interestingly, men without a history of bone disease or fractures were just as likely to have osteopenia or osteoporosis on DEXA scan as women without history of bone disease or fractures, 54% compared to 61% (p=0.27).

Conclusion: Men with primary hyperparathyroidism are less likely to undergo DEXA scans compared to women. However, our work shows that men and women with no history of bone disease or fractures are equally likely to have osteopenia or osteoporosis on a DEXA scan. These data suggest that the incidence of osteopenia and osteoporosis is likely higher in men than current literature indicates, and that men with a diagnosis of primary hyperparathyroidism without history of bone disease or fractures would benefit from evaluation by DEXA scan.

 

33.06 Adrenal Venous Sampling vs. Imaging for Surgical Decision Making in Primary Hyperaldosteronism

Posted on January 31, 2019

J. Shank1, N. Nagarajan1, B. Holly2, A. Mathur1, J. Canner1, J. D. Prescott1  1Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Radiology And Radiological Sciences,Baltimore, MD, USA

Introduction:
Adrenal venous sampling (AVS) is the gold standard test for lateralizing aldosterone hypersecretion/identifying bilateral disease in cases of primary hyperaldosteronism. Though efficacious, AVS is expensive, invasive, requires significant technical expertise and is not universally available. The utility of less expensive, less morbid imaging techniques for disease lateralization has been limited by relatively poor associated sensitivity and specificity. Nonetheless, medical imaging technology is continually improving, making periodic reassessment of imaging lateralization accuracy, relative to AVS, necessary.

Methods:
A retrospective review was performed to identify patients who underwent AVS between July 1st 2003 and April 30th 2015 at our academic tertiary care center. Patients were excluded if AVS was not performed for hyperaldosteronism, if CT and/or MRI adrenal imaging was not done and if disease management was unknown. Data were extracted for demographic, clinical, biochemical and treatment variables. Continuous variables were summarized using medians and interquartile range (IQR). Binary/categorical variables were summarized as proportions.

Results:
A total of 204 AVS patients were identified, of whom 112 met inclusion criteria. Overall, 71 patients underwent unilateral adrenalectomy. Among the 53 patients in this group having concordant AVS and imaging findings, postoperative serum aldosterone values were available for 34, with biochemical cure achieved in 32 (94.1%). When AVS and imaging were discordant (n=14), AVS lead to surgical cure in 77.8 % of patients, none of whom would have been referred for surgery on the basis imaging findings alone (bilateral adrenal nodules). When discordant, 4 patients underwent surgery based on imaging postoperative aldosterone was only available for 1 patient who showed biochemical cure. Among the 41 patients treated medically, concordance was 48.8%, with discordance resulting primarily from unilateral imaging findings in the context of bilateral AVS results. Overall, an imaging only-based management plan was, or would have been, incorrect in 28.6% of the cohort (inappropriate surgery or inappropriate medical management).

Conclusion:
Our findings identify high discordance rates between AVS and contemporary abdominal imaging techniques when assessing disease laterality among patients diagnosed with primary hyperaldosteronism. AVS thus remains critical to accurate clinical decision-making for these patients.
 

33.05 Specific Growth Rate as a Predictor of Survival in Pancreatic Neuroendocrine Tumors

Posted on January 31, 2019

J. J. Baechle1, P. M. Smith2, M. Tan2, C. Bailey2, C. Solorzano2, A. G. Lopez-Aguiar3, M. Dillhoff4, E. W. Beal4, G. Poultsides5, E. Makris5, F. G. Rocha6, A. Crown6, C. Cho7, M. Beems7, E. R. Winslow8, V. R. Rendell8, B. A. Krasnick9, R. Fields9, S. K. Maithel3, K. Idrees2  1Meharry Medical College,School Of Medicine,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 3Emory University,Department Of Surgery,Atlanta, GA, USA 4Ohio State University,Comprehensive Cancer Center,Columbus, OH, USA 5Stanford University Medical Center,Palo Alto, CA, USA 6Virginia Mason Medical Center,Seattle, WA, USA 7University Of Michigan,Hepatopancreatobiliary And Advanced Gastrointestinal Surgery,Ann Arbor, MI, USA 8University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA 9Washington University,School Of Medicine,St. Louis, MO, USA

Introduction:  Pancreatic neuroendocrine tumors (PNETs) are often indolent, but rapidly progressing variants have been reported. To better inform prognosis and treatment decisions, improved understanding of patients at-risk for rapidly progressing PNETs is critical, particularly for patients with small PNETs who may be candidates for expectant management under current treatment guidelines. Specific growth rate (SGR) has been demonstrated in multiple malignancies to be predictive of overall and disease-free survival, but SGR has not been examined in PNETs. The aim of this study is to determine the predictive value of SGR on oncological outcomes in patients with PNETs.

Methods:  A retrospective cohort study of adult patients who underwent surgical resection of PNET from 2000-2016 was performed utilizing the multi-institutional U.S. Neuroendocrine Study Group database. Patients with PNET and more than one pre-operative cross-sectional imaging study at least thirty days apart were included in our analysis. The tumor SGR (% growth/day) was calculated using the tumor diameters measured on initial (Di) and final (Df) pre-operative imaging utilizing the previously published equation: SGR = 3ln(Di-Df)/ΔT. Patients with a SGR above the ninetieth percentile were termed “high SGR” and the remaining patients were termed “low SGR”. Overall survival (OS) was analyzed by Kaplan-Meier method and log-rank test. Cox proportional hazard models were used to assess the impact of SGR on OS after adjusting for patient and tumor characteristics. 

Results: Of the 1,247 PNET patients who underwent resection, 288 (23%) had two or more pre-operative cross-sectional imaging studies at least 30 days apart. High SGR was associated with higher T Stage at resection (p=0.01), shorter doubling time (p<0.01), and elevated HbA1c (p=0.01). Patients with high SGR also had significantly decreased 5-year OS and disease-specific survival (DSS) compared to those with low SGR (63 vs 80%, p=0.01, Figure 1a; 72 vs 86%, p=0.03, Figure 1b). In patients with small (≤2cm) tumors, high SGR predicted lower 5-year OS (85 vs 91%, p=0.01, Figure 1c). When examining all patients by multivariate analysis controlling for T, N, M stage and HbA1c, high SGR was independently associated with worse OS (Hazard Ratio 2.67, 95% Confidence Interval 1.05 – 6.84, p=0.04).

Conclusion: High SGR in PNETs, including small tumors (<2cm), is associated with worse survival. High SGR can potentially be utilized as a useful marker in the clinical decision process particularly when weighing close observation versus surgical resection in patients with small PNETs.

 

33.04 Comparison of ATA and ACR Scoring Systems for Thyroid Nodule Ultrasound Characteristics

Posted on January 31, 2019

R. Pudhucode1, H. Chen2, B. Lindeman2  1Alabama College of Osteopathic Medicine,Dothan, ALABAMA, USA 2University Of Alabama at Birmingham,Division Of Surgical Oncology, Department Of Surgery,Birmingham, Alabama, USA

Introduction:
Thyroid nodules are commonly found in clinical practice. Previously, it was routine for any nodule over 1.0 cm in size to undergo fine needle aspiration (FNA) biopsy. The American Thyroid Association (ATA) published new guidelines in 2015 that recommend thyroid nodule FNA biopsy be based on size plus ultrasound characteristics. In 2016, the American College of Radiology (ACR) introduced a different set of ultrasound-based guidelines called the Thyroid Imaging Reporting and Data System (TIRADS) to assess the need for biopsy of thyroid nodules. The ATA guidelines utilize a pattern-based approach to identify nodule characteristics associated with malignancy. The ACR TIRADS utilizes a point system to assess the degree of risk for malignancy of each ultrasound characteristic.

Methods:
This study aims to evaluate the recommendations for thyroid nodule FNA biopsy between the two scoring systems in a historical cohort of patients with a diagnosis of cancer on surgical pathology. Ultrasound characteristics, FNA biopsy, and surgical pathology results were evaluated for all patients with a diagnosis of thyroid malignancy treated at the University of Alabama at Birmingham (UAB) from 2010 – 2016. Patients with Graves’ disease, thyrotoxicosis, and incomplete records were excluded.

Results:
Of 285 thyroid nodules studied, 34.4% (n=98) were found to have discordant recommendations for FNA biopsy between the ATA and ACR systems. For all 98 discordant nodules, the ATA guidelines recommended biopsy, while the ACR system did not. Nodules <1.0 cm in size which would not be recommended for biopsy in either present-day classification system comprised 31.2% (n=89) of the study population.  Excluding the 89 sub-centimeter nodules, 50% of patients with thyroid cancer would have been missed if the ACR system alone were used. On FNA biopsy, 59.0% of the discordant nodules were classified as malignant. Among nodules 1.0 – 1.4 cm in size, the ACR system missed 45 nodules (45.9%); 35 of which were malignant on final pathology (77.8%). For nodules 1.5 – 1.9 cm in size, 16 (16.3%) were missed by the ACR system, 15 of which were malignant (93.8%). Similarly, for nodules 2.0 – 2.4 cm in size, 9 out of 12 discordant nodules were malignant (75.0%). Lastly, for those nodules over 2.5 cm in size, 23 out of 25 discordant nodules (92.0%) were malignant on final pathology.

Conclusion:
If the ACR classification system alone had been utilized, 50% of patients with thyroid cancers 1.0 cm and larger treated at UAB between 2010 – 2016 would not have had their nodules biopsied. This could have resulted in delays in diagnosis and/or therapy for these patients.
 

33.03 Challenges in the Management of Adrenal Incidentalomas: One Year at an Urban Level I Trauma Center

Posted on January 31, 2019

T. Feeney1,2, S. Talutis1,2, M. Janeway1,2, P. Sridhar1,2, A. Gupta3, P. Knapp4, J. Moses5, D. McAneny1,2, F. T. Drake1,2  1Boston Medical Center,Surgical Endocrinology,Boston, MA, USA 2Boston University School of Medicine,Surgery,Boston, MA, USA 3Boston University School of Medicine,Radiology,Boston, MA, USA 4Boston University School of Medicine,Medicine,Boston, MA, USA 5Boston University School of Medicine,Pediatrics,Boston, MA, USA

Introduction: Incidental findings, including adrenal masses, are increasingly common, and their management is challenged by poor communication, determination of responsibility, the infrequency of clinical significant, and competing health considerations. Clear guidelines exist for the evaluation of incidental adrenal masses, but barriers to implementation are not well understood. The goal of the current study was to evaluate usual care practice patterns for follow-up of incidental adrenal masses at an urban Level 1 trauma and tertiary referral center.  

Methods:  A retrospective review of medical records for all patients with an incidentally-discovered adrenal mass at a tertiary medical center in Boston, MA and associated ambulatory care locations. All individuals ≥18 years old with a mass identified during 2016 were included. Patterns of evaluation, follow-up, and associated adrenal diagnoses were determined.

Results: 244 patients were identified from approximately 19,171 eligible scans. Median age = 63 years; median size = 1.5cm. Most patients (85%) had a single lesion, and 51% of imaging was performed during an ED evaluation. Of the 244 patients, 31 (12.7%) appropriately did not undergo adrenal evaluation due to severity of comorbid conditions. Among the remaining 213, 38 were lost to follow-up and only 20 had a PCP evaluation. Of those with an identifiable PCP, 118 (80%) had a PCP within our health system. Dedicated adrenal evaluation (imaging and/or labs) was performed by a PCP in only 9% of patients (16/175). Patients were more likely to undergo follow-up if the mass was characterized in the radiology report as “indeterminate” versus “benign” (65% vs 30% p<0.001). Of 130 patients with hypertension, only 2 (3.2%) underwent aldosterone/renin screening. Of 53 patients with co-morbid conditions potentially related to Cushing’s Syndrome, 0 patients had appropriate hormonal evaluation. Four patients (1.9%) had hormonal evaluation for pheochromocytoma. Among all 244 patients, our review yielded 71 patients with some diagnosis listed in the chart (including, simply, “adrenal nodule.”) including 1 cortisol secreting mass and 8 metastases.  

Conclusion: Under usual care, most patients with an incidental adrenal mass do not undergo workup described in published guidelines. A potential contributing factor is detection during ED evaluations, which challenges follow-up. Nine of 213 adrenal masses (4.2%) were clinically significant; however, according to available literature, we would have expected up to 25%, or 53 masses, to be. This discrepancy suggests that published estimates are not necessarily generalizable to all healthcare settings or that usual care is inadequate to detect clinically significant lesions. This discrepancy between guidelines and usual care offers a clear quality improvement opportunity, and we have implemented a prospective initiative to facilitate communication and evaluation of incidental adrenal masses.

33.02 Post-thyroidectomy Neck Appearance and Impact on Quality of Life in Thyroid Cancer Survivors

Posted on January 31, 2019

S. Kurumety1, I. Helenowski1, S. Goswami1, B. Peipert1, S. Yount2, C. Sturgeon1  2Feinberg School Of Medicine – Northwestern University,Department Of Medical Social Sciences,Chicago, IL, USA 1Feinberg School Of Medicine – Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:  There is a paucity of patient-reported data on thyroidectomy scar perception. The magnitude and duration of the impact of thyroidectomy scar on quality of life (QOL) is not known. We hypothesized that age, sex and race would predict scar perception, and that worse scar perception would correlate with lower?QOL. Furthermore, we hypothesized that over time, scar perception would improve.

Methods: Adults >18 years who had undergone thyroidectomy for cancer?(n=1743)?were recruited from a support group and surveyed online. Demographics, clinical characteristics, and treatment history were assessed. Scar perception was scored on a 5-point Likert scale.?QOL was evaluated via PROMIS-29. Respondents were grouped and compared based on their responses. The relationship between scar perception, patient characteristics, and QOL were?analyzed?with univariable and multivariable?models. Kruskal-Wallis, Fisher’s exact test, and cumulative logistic regression were used to compare?categorical variables. The relationship?between PROMIS domains and scar perception?were?analyzed using Spearman partial correlation coefficients?(r)?adjusted for age and years after surgery.?Holms-Bonferroni was used to correct for multiple comparisons.

Results: Increasing age?was associated with?better?scar perception (OR 0.975/year; 95% CI 0.967-0.983; p<0.001).?71% of respondents age >45?years?reported no concern over scar, compared to only 53% of respondents?<45;?p < 0.0001. Increased time since surgery?was?also associated with?improved?scar perception (OR 0.962/year; 95% CI 0.947-0.977; p<0.0001), but there was no statistically significant difference between current and baseline neck appearance >2 years after surgery. On multivariable analysis, age >45 years (OR 0.65; [0.52-0.81] p=0.0001), >2 years since surgery (OR 0.57; 95% CI 0.46-0.70; p<0.0001), and higher self-reported QOL (OR 0.77; 95% CI 0.67-0.89; p=0.0003) were independent predictors of better self-reported scar appearance. In patients <2 years after surgery (n=568), the PROMIS domains of anxiety (rs=0.19; p<0.0001), depression (rs=0.21; p<0.0001), social function (rs=-0.18; p<0.0001), and fatigue (rs=0.21; p<0.0001) had weak but statistically significant associations with worse scar appearance. Sex and race/ethnicity were not associated with scar perception.

Conclusions: This is the largest study conducted in the U.S to evaluate scar perception after thyroidectomy, and the first to use PROMIS measures.??Age >45, >2 years since surgery, and higher self-reported QOL were independent predictors of better scar perception.??There was no significant difference between perception of current and baseline neck appearance in the group of respondents >2 years after thyroidectomy. There was a weak correlation between scar perception?and?PROMIS domains in patients who had surgery within 2 years. The impact of thyroidectomy scar on QOL appears to be mild and transient and plateaus after 2 years.

33.01 Intraoperative recurrent laryngeal nerve oedema affects post-operative voice quality

Posted on January 31, 2019

J. C. Lee1,2 1The Alfred, Melbourne, Victoria, Australia 2Monash Health, Dandenong, Victoria, Australia

Introduction: Over the last 150 years thyroid surgery has been transformed from a procedure with high mortality to a very safe one. However, recurrent laryngeal nerve (RLN) injuries continue to occur. This study examined the differential palsy rates between the left and right RLNs, and the role of intraoperative nerve swelling as a risk factor of postoperative palsy.

Methods: Thyroidectomy data of patients of the Monash University Endocrine Surgery Unit were collected from 13 institutions, including demographics, pathology, and change in RLN diameter (subgroup). Voice quality was scored subjectively using the Voice Disorder Index and objectively using the Dysphonia Severity Index (DSI), before and after operation, in a subgroup.

Results: A total of 5,334 RLNs were at risk in 3,408 thyroidectomies in this study. The overall RLN palsy rate was 1.5%, greater on the right side than the left for bilateral cases (P = .025), and greater on the left side than the right for unilateral cases (P = .007). The diameter of the right RLN was larger than the left RLN, both at the beginning and end of the dissection (P = .001). The RLN diameter increased by approximately 1.5-fold (P < .001). In hemithyroidectomy patients, the greater the increase in recurrent laryngeal nerve diameter, the worse the post-operative DSI score (P = .03). Patients who underwent either hemi- or total thyroidectomy both reported significant deterioration of voice. However, on objective assessment, only total thyroidectomy patients showed significant deterioration (Mean DSI 4.0 ± 0.3 – 2.5 ± 0.3, P < .01). Conclusion: As we embark on new and innovative thyroidectomy techniques, it is important to review the anatomical and functional details of the RLN. It is also paramount that we do not compromise patient outcomes while developing minimally invasive techniques.

32.10 Cost Awareness of Common Surgical Supplies is Severely Limited Regardless of Role and Experience

Posted on January 31, 2019

R. Sorber1, D. Stobierski2, G. Dougherty2, C. Kang3, Y. Lum1,2  1The Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Bloomberg School Of Public Health,Baltimore, MD, USA 3The Johns Hopkins University School Of Medicine,School Of Nursing,Baltimore, MD, USA

Introduction:

Increasing concerns regarding healthcare costs have triggered interest in reducing operating room waste, but the overall level of awareness of costs among the team members making intraoperative decisions regarding supply selection remains unclear. This work characterizes the knowledge of supply costs among surgeons as well as operating room staff in a large academic hospital and seeks to examine the contribution of operating room role and years of experience with regards to cost awareness. 

Methods:

This work is a cross-sectional study of surgeons, surgical trainees, operating room nurses and surgical technicians (n=372) across all surgical specialties at the Johns Hopkins Hospital. Participants completed a survey reporting frequency of use and estimated cost for the eleven commonly used surgical supplies. They were also asked to render opinions on the role of cost in surgical decisionmaking and their desire for increased access to cost information. Responses were stratified by respondent role as part of the surgical team and years of experience. All data was analyzed using Stata to perform ANOVA and Χ2 testing as well as linear regression modeling.

Results:

Cost estimates ranged widely, with most respondents overestimating supply costs of most inexpensive items by 1.3-3.2 times the actual cost and underestimating the two most expensive items (0.87-0.89 times actual cost). There was no significant difference in accuracy of cost estimation when stratified by role, years of experience, item, or frequency of item use. The vast majority of respondents (88.7%) expressed agreement that cost should factor into surgical decisionmaking as well as a desire to learn more regarding cost of common supplies.

Conclusion:

Accurate knowledge of the cost of common surgical supplies is severely limited among surgeons, surgical trainees and operating room staff with no correlation to years of experience or frequency of use. While concerning, this lack of knowledge coexists with a strong desire to augment cost awareness. Improved access to cost information across disciplines has high potential to inform surgical decisionmaking and potentially decrease operating room waste.

 

32.09 Debunking the July Effect: Systematic Review and Novel Difference-in-Difference Analysis

Posted on January 31, 2019

C. K. Zogg1,2,3, D. Metcalfe3, S. A. Hirji2, K. A. Davis1, A. H. Haider2  1Yale University School Of Medicine,New Haven, CT, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University of Oxford,Oxford, United Kingdom

Introduction: The arrival of new residents at the beginning of the academic year has long been associated with perceived adverse patient outcomes. Numerous studies in recent years have sought to prove/disprove the ‘July Effect.’ The objective of this study was to provide a definitive answer, combining data on mortality, morbidity, and unplanned readmission through a systematic review/meta-analysis and expanded difference-in-difference (DID) analysis of seasonal variation in outcomes for teaching vs non-teaching hospitals across seven common medical and surgical conditions.

Methods: 1) Systematic review and meta-analysis of studies published prior to July 31, 2018. 2) DID analysis of adult patients, ≥18y, with primary diagnosis/procedure codes for AMI, CVA, pneumonia, elective CABG, elective colectomy, craniotomy, or hip fracture contained within the 2012-2015 Nationwide Readmissions Database. Weighted models compared disease-specific differences in 30- and 90-day mortality, readmission, and median index hospital length of stay (LOS) between patients admitted to teaching vs non-teaching hospitals in July-August vs September-June and April-May.

Results: A total of 85 studies met inclusion criteria. Of these, 12 (14.1%) reported evidence in support of a July Effect for any outcome (1/13 high-quality studies). An additional 14 (16.5%) suggested that evidence was mixed (3/13 high-quality studies). 57/85 assessed mortality, of which 25 were eligible to be included in the random effects meta-analysis (Figure), OR(95%CI): 1.00(0.97-1.03). 48/85 assessed major morbidity, of which 26 were included in the random effects meta-analysis, 1.02(0.99-1.05). One met inclusion for readmission, 0.90(0.80-1.23). Data assessment similarly revealed no significant differences in 30- or 90-day mortality when comparing teaching vs non-teaching hospitals in July-August vs April-May (e.g. absolute 30-day DID[95%CI] hip fracture: +0.1[-0.7 to +0.9] percentage-points). When compared relative to September-June, AMI showed a slight 30-day difference, +0.4(0.1-0.8) percentage-points, that was not significant for p<0.001. Similar results were observed for 30- and 90-day readmission (e.g. 30-day hip fracture: -0.2[-2.0 to +1.6] percentage-points) and median index hospital LOS (0.0[0.0-0.0] days).

Conclusion: An influx of recent studies has challenged pre-existing notions of the July Effect for major adverse outcomes: mortality and morbidity. While evidence refuting the July Effect in readmission is scarcer, DID assessment of common medical and surgical conditions demonstrated that the July Effect does not exist. Taken together, the results suggest that fears surrounding the July Effect are unfounded and that further studies might be unwarranted.

32.08 Quantifying Documentation Burden Using the Electronic Medical Record.

Posted on January 31, 2019

G. J. Eckenrode1, H. Yeo1  1Weill Cornell Medical College,Surgery,New York, NY, USA

Introduction:
Time spent on clinical documentation is frequently cited as a contributing factor in physician burnout. Many physicians believe that the amount of patient documentation, both in terms of number of documents required as well as total length of documents, is increasing and has created a significant burden. There is a paucity evidence regarding the actual volume of increase and the amount of documentation taking place.

Methods:
We used a database of text-based clinical documents extracted from the inpatient electronic medical record (EMR) of a single institution. This database was established in 2014 and aggregates all electronic medical information for all patients treated by a large gastrointestinal surgery center within the institution. It contains notes dating from the widespread adoption of electronic medical documentation in approximately 2006 to the present day. We extracted all physician-visible text-based notes for each patient’s entire hospital stay for analysis. The number of notes and the word count for each note was calculated for each patient for each day.

Results:
The database contains 141,480 unique patient identification numbers and 10,925,542 physician-visible inpatient notes. Notes prior to 2007 were excluded due to low daily volume reflective of low document capture by the database. We found 1,591 note types as labeled by the EMR. The range of patients receiving notes on any given day ranged from 250 – 350 patients in 2007 with a steady increase to 400 – 1100 patients at the end of 2017. The average number of notes per patient was 77 with a range of 1 – 10,000. The average number of notes per patient per day remained constant over time, with a range of 4-6 but the number of words per patient per day rose constantly with time from 4,000 – 6,000 in 2008 to 12,000 – 14,000 per day at the end of 2017, a 3-fold increase.  

Conclusion:
While the number of notes per patient per day has been constant over time, the number of words per note have increased markedly. Over the past decade, at this single institution patient documentation has increased in both quantity and complexity, requiring more work from physicians to create and manage, increasing the burden of clinical care.
 

32.07 How Much is Enough? A Crowd-Sourced Public Opinion Survey on Minimum Surgeon Volumes

Posted on January 31, 2019

J. Danford1, D. Underbakke2, B. Sirovich1, S. Wong1,2, M. Sorensen1,2  1Geisel School of Medicine at Dartmouth,Hanover, NH, USA 2Dartmouth-Hitchcock Medical Center,General Surgery,Lebanon, NH, USA

Introduction:  In the past 15 years, numerous investigators have demonstrated an association between surgeon volumes and outcomes.  From this body of literature, there have been attempts to quantify minimum volume standards for specific surgeries. Despite the growing body of literature on the subject, little has been reported on the impact of this research on public perception of surgeon competency.

Methods:  A survey on public perception of the importance of surgeon volumes was designed using a modified Delphi technique and completed by participants using Amazon Mechanical Turk, an online crowdsourcing marketplace. Respondents completed a 38-question survey on their opinion of minimum volume standards and other factors that may influence their choice of surgeon. They were also asked to estimate minimum volume standards for four different surgeries, and to consider the implications of published minimum volume numbers in two diagnostic scenarios. 

Results: The survey was completed by 2,056 people. The respondents were 51% male, 49% female. Median age range was 30-39 years old.

Overall, 81% (n=1,666) of people agreed that surgeons should be subject to minimum volume standards. Only 19% (n=384) reported having prior knowledge about a link between surgeon volumes and outcomes. 

Respondents accurately estimated the published suggested minimum volume standard for inguinal hernias of 25. For knee replacement surgery, respondents estimated a minimum of 30 per year: 1.5 times the published minimum volume standard of 20. For mitral valve repair, respondents estimated 44 per year: 4.4 times the published minimum volume standard of 10. For pancreaticoduodenectomy, respondents estimated 44 per year: 8.8 times the published minimum volume standard of 5.

When posed with the scenario of needing an inguinal hernia repair, 77% (n=1,584) said they would require their surgeon to have met a minimum volume standard to proceed with surgery. If told their surgeon performed 25 per year (the published suggested minimum volume standard), 55% (n=1,127) of respondents would feel comfortable proceeding with surgery. However, when posed with needing a pancreaticoduodenectomy, 92% (n=1,877) said they would require their surgeon to have met a minimum volume standard. And when told their surgeon did 5 per year (the established minimum volume standard), only 13% (n=265) would feel comfortable proceeding with surgery.  

Conclusion: This survey suggests that surgical volumes are important to the lay public. However, it also demonstrates the general public’s unrealistic expectations of minimum volume standards and inability to interpret surgical volume numbers when attempting to use them to judge a surgeon’s competence. This study has implications for patients, surgeons, hospitals, and policy makers when considering the implementation of minimum volume standards and how best to educate the public about this aspect of choosing a surgeon.
 

32.06 Enhanced Recovery After Surgery for Hysterectomy Shortens Hospital Stay and Reduces Care Disparity

Posted on January 31, 2019

S. M. Stapleton1,2, R. M. Sisodia1,2, D. C. Chang1,2, N. P. Perez1,2, B. V. Udelsman1,2, M. G. Del Carmen1,2, K. D. Lillemoe1,2  1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA

Introduction:  Multi-modal approaches for enhanced recovery after surgery (ERAS) represent evidence-based protocols designed which standardize peri-operative care, to improve patient outcomes and reduce cost to the health system. ERAS protocols were first developed for use in the field of colorectal surgery. More recent efforts seek to expand implementation throughout surgical and nonsurgical specialties. We aim to evaluate implementation of an ERAS protocol within the department of obstetrics and gynecology. We hypothesize that care standardization will reduce length of stay in a field that does not routinely perform bowel surgery.

Methods:  An observational study at a tertiary academic medical center was performed for the 12-months pre- and 6-months post-ERAS implementation. Female patients with ICD10 codes for elective hysterectomy were included. In-hospital deaths were excluded. Endpoints assessed included length of stay (LOS), and likelihood of same-day discharge or readmission. Multivariable analysis adjusted for ERAS, minimally invasive vs. open hysterectomy, procedure performed for malignancy, and case start time. Difference-in-difference analyses were performed by race.

Results: We analyzed 1004 hysterectomies, 88.9% (n=812) lap and 98.3% (n=987) for benign disease. Hospital duration was significantly reduced post-ERAS (24.2 [IQR11.4-28.5] hrs. vs. 13.1 [IQR10.6-27.7] hrs., p=<0.01). Additionally, hospital duration was significantly reduced post-ERAS for patients staying <24 hrs. (13.0 hrs. pre vs. 11.9 hrs. post, p=0.01), but interestingly the opposite trend was observed for patients staying >24 hrs. (47.8 hrs. pre vs. 65.2 hrs. post, p=0.02). Furthermore, rates of same-day discharge increased significantly post-ERAS (49.1% for pre vs. 63.2% for post, p=<0.01). There was no significant difference in readmission rates (15.7% pre vs. 18.1% post, p=0.34). When stratifying into pre-ERAS vs. post-ERAS, same-day discharge rates were 50.4% vs. 45.5% pre-ERAS, and 63.3% vs. 62.9 post-ERAS for whites vs. non-whites respectively (figure). Lastly, cases started before 1pm were significantly more likely to be discharged on the same day as the surgery (OR 1.26, p=0.07).

Conclusion: As an example of value-based care, ERAS is effective in reducing hospital duration by increasing rates of same day discharge through identifying borderline patients who would otherwise stay an additional day. Additionally, ERAS is effective in reducing racial disparity in care, suggesting that standardization of care pathways may reduce bias in decision making. Lastly, future ERAS protocols may consider supplementing current practices with systems level interventions, such as starting complex cases that are eligible for same-day discharge before 1 pm.

 

32.05 What Data Do Patients Want to Use in Choosing a Provider? A National Survey of Patient Preferences

Posted on January 31, 2019

R. J. Ellis1,2, D. B. Hewitt3, J. K. Johnson4, K. Y. Bilimoria1  1Northwestern University,Department Of Surgery, Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2American College of Surgeons,Chicago, IL, USA 3Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA 4Northwestern Feinberg School of Medicine,Center For Healthcare Studies In The Institute Of Public Health And Medicine,Chicago, IL, USA

Introduction:  Patient utilization of healthcare quality reporting has been suboptimal despite attempts to encourage use of publicly available data. Lack of utilization may be due to discordance between reported quality metrics and what patients want to know when making healthcare choices. The objectives of this study were (1) to identify hospital- and physician-level measures of quality that patients would prefer presented in public reporting and (2) to explore the relative importance of these factors in how patients assess healthcare quality during decision making.

Methods:  Interviews and focus groups were used to develop and refine a survey exploring the relative importance of healthcare quality measures. Measures were studied across all domains of healthcare quality, including hospital-level measures (e.g., location, accreditations, hospital-level outcomes) and physician-level measures (e.g., years of experience, training program, adherence to national guidelines). The survey was administered to online survey panels through SurveyGizmo to obtain a census balanced national sample. Likert scale responses were compared using non-parametric tests of central tendency. Rank order responses were compared using analysis of variance testing adjusted for multiple comparisons. Associations with binary outcomes were analyzed using multivariable logistic regression models.

Results: The survey was sent to 11,125 individuals with 4,672 responses (42.0% response rate). Census balancing yielded 2,004 surveys for analysis. Of those, 1,213 (60.5%) reported previously researching healthcare online. Measures identified as most important were hospital reputation (considered important by 61.9%), physician years of experience (51.5%), and primary care physician recommendations (43.2%). Relatively unimportant factors included adherence to national guidelines (17.6%), risk of requiring temporary nursing home care (17.5%), and hospital academic affiliation (13.3%, p<0.001 for all compared to most important factors). Outcome measures were not among the most important factors, with the risk of death considered important by only 35.1% of respondents. Patients were unlikely to rank outcome measures as the most important factors in choosing healthcare providers, irrespective of age, gender, educational status, or income.

Conclusion: In selecting providers, patients valued hospital reputation, physician experience, and primary care physician recommendations. Publicly reported metrics like guideline adherence and patient outcomes were considered less important, despite a national push to focus on outcomes in public reporting. Public quality reports contain information that patients perceive to be of relatively low value, which may contribute to low utilization of public healthcare quality information. Development of reporting systems focused on relevant, patient-centered information may improve patient utilization of publicly reported quality data.

32.04 Behind the Mask: Gender Bias Experiences of Female Surgeons

Posted on January 31, 2019

K. L. Barnes1, L. McGuire3, G. Dunivan1, A. Sussman4, R. McKee2  1University Of New Mexico HSC,FPMRS/Obstetrics And Gynecology,Albuquerque, NM, USA 2University Of New Mexico HSC,Colorectal Surgery/General Surgery,Albuquerque, NM, USA 3University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA 4University Of New Mexico HSC,Family And Community Medicine,Albuquerque, NM, USA

Introduction: The number of female surgeons continues to rise, however reports of sexism and stigmatization in the clinical setting continue. Although, overt sexism is becoming increasingly rare, underlying prejudices held against women are frequently expressed as microaggressions- subtle discriminatory or insulting actions that communicate demeaning or hostile messages at the interpersonal level.  We sought to assess the frequency and severity of gender-based microaggressions experienced by female surgeons.

Methods: This mixed methods approach utilized both focus groups and questionnaires to explore female surgeons’ experiences of gender bias in the form of microaggressions. The Sexist Microaggression Experiences and Stress Scale (Sexist MESS), a validated, 44-item questionnaire, was used to quantify the frequency and psychologic impact of gender-based microaggressions. This questionnaire consists of six domains, with higher scores indicating more frequent or severe microaggression impact. We conducted focus groups with female surgeons to explore their unique experiences of workplace gender bias and developed 15 additional questions. These questions were added to the survey and sent to all female resident, fellow and attending surgeons at a single academic institution.

Results: Four focus groups including 23 female trainee and attending surgeons were conducted revealing four emerging themes: Exclusion, Adaptation, Increased Effort, and Resilience. The survey response rate was 64.3% (65/101 surgeons). Survey data showed that the frequency and severity of microaggressions was higher in 5 of 6 domains for trainees compared to attending surgeons (Table 1), with the exception of “Inferiority”. When Obstetrician Gynecologists (OB/GYN) were compared to all other surgeons, rates of reported microaggressions were similar in all domains except “Leaving Gender at the Door”. Non-OB/GYN surgeons reported more pressure to downplay, hide or avoid characteristics and behaviors associated with femininity in order to succeed. The variables of non-white race, currently providing childcare, and number of years in practice after training did not demonstrate statistical significance.

Conclusion: The extent and psychological impact of microaggressions experienced by female surgeons varies based on level of training, with higher rates reported by trainees compared to attending surgeons. The type of surgical specialty practiced made little difference, with OB/GYN and non-OB/GYN surgeons describing similar experiences. Higher frequency and severity scores for the domain “Leaving Gender at the Door” reported by non-OB/GYN surgeons may be explained by the lower proportion of women in these fields compared to OB/GYN. 

32.03 Prospective Identification of Costly Surgical Episodes

Posted on January 31, 2019

K. R. Chhabra1,3,4, U. Nuliyalu4, J. B. Dimick2,3,4, H. Nathan2,3,4  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 3University Of Michigan,IHPI Clinician Scholars Program,Ann Arbor, MI, USA 4University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA

Introduction:
Surgery accounts for almost half of inpatient spending, much of which is concentrated in a subset of high cost patients. A method of prospectively identifying high cost patients, i.e. “hot spotting,” may help manage population health spending, but we lack an optimal way to predict which patients will have high-cost surgical episodes.

Methods:
Using 100% Medicare claims data, we identified patients aged 65-99 undergoing elective inpatient surgery (CABG, colectomy, total hip/knee replacement) in 2014. We calculated price-standardized Medicare payments for the surgical episode from admission through 30 days after discharge (episode payments). Based on predictor variables from 2013, e.g. Elixhauser comorbidities, hierarchical condition categories, Medicare’s Chronic Conditions Warehouse (CCW), and total spending, we constructed models to predict the costs of surgical episodes in 2014. We used general linear mixed models incorporating hospital random effects and adjusting for age, sex, and race, testing fit with R2 and kappa statistics (κ) using quintiles of spending.

Results:
A cost prediction model based on CCW score performed well in predicting payment variation for all procedures (R2 0.16-0.22, κ 0.13-0.15; all P<0.001). Other models also had statistically significant R2 and κ but had inferior predictive performance to CCW. The costliest quintile of patients as predicted by the model captured 40-50% of the patients in each procedure’s actual costliest quintile. For example, in CABG, 48% of the costliest quintile was predicted by the model’s costliest quintile. A greater share of the costliest quintile was identified when the prediction threshold was lowered; e.g. in CABG 73% of the actual costliest quintile was identified by combining the model’s 2 top quintiles of predicted cost.  

Conclusion:
Expensive surgical patients can be prospectively identified using readily available data on patients’ chronic conditions. The sensitivity of the cost prediction model can be tailored as desired. For instance, if attempting to identify as many potentially expensive patients as possible, one may lower the threshold for detection by combining quintiles of predicted cost. 

32.02 Impact of Medicare Readmissions Penalties for Surgical Conditions

Posted on January 31, 2019

K. R. Chhabra1,2,4, A. M. Ibrahim2,3,4, J. R. Thumma2, J. B. Dimick2,3,4  1Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 2University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 3University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 4University Of Michigan,IHPI Clinician Scholars Program,Ann Arbor, MI, USA

Introduction:
The Hospital Readmissions Reduction Program, announced in 2010 to penalize excess readmissions for patients with select medical diagnoses, was expanded in 2013 to include targeted surgical diagnoses beginning with hip and knee replacements. The impact of these procedure-specific penalties for targeted procedures is not well understood.

 

Methods:  
A retrospective review of 2,627,974 patients who underwent total hip replacement or total knee replacement from 100% fee-for-service Medicare claims.  We used an interrupted time series model to assess hospital rates of readmission before the Hospital Readmissions Reduction Program was announced (2008-2010), during implementation for medical conditions (2010-2013) and after specific hip/knee replacement penalties were announced (2013-2016). We also assessed trends in length of stay and the use of observation status.

 

Results:
From 2008 to 2016, readmission rates declined for total hip replacement (7.8%–5.6%) and total knee replacement (7.0%–5.2%). Readmission rates were decreasing in 2008-2010, but the decline accelerated after the announcement of Hospital Readmissions Reduction Program in 2010 (slope change ?0.06 to -0.09). Readmissions continued to decrease after targeted surgical procedures were announced in 2013, but at a slower rate (slope change -0.09 to -0.05). During the same time period, mean length of stay decreased (3.6 d–2.4 d for total hip replacement, 3.6–2.5 d for total knee replacement). There was no change in the trend of observation status use before and after the Hospital Readmission Reduction Program.

 

Conclusions:
The major reduction in surgical readmissions rates occurred after the initial announcement of the Hospital Readmission Reduction Program, rather than after penalties for specific surgical procedures were announced. These findings suggest that the initial policy (for medical conditions) had a broad spillover effect, leading to improvements in surgical readmission rates as well.

32.01 Human Performance Analysis in Surgery – Cognitive and Technical Performance Improvement Opportunity

Posted on January 31, 2019

J. Suliburk1, C. Ryan1, Q. Buck1, C. Pirko1, N. Massarweh1, N. Barshes1, S. Awad1, S. R. Todd1, H. Singh2, T. Rosengart1  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Baylor College Of Medicine,DeBakey VA Medical Center For Innovations In Quality, Effectiveness And Safety / Department Of Internal Medicine,Houston, TX, USA

Introduction: Surgical quality improvement efforts have largely focused on data registries and process improvement strategies to overcome the role of human performance deficiencies (HPD) in catalyzing adverse outcome.  Limited data are available in quantifying the prevalence and types of HPD in surgical complications. The purpose of this prospective study was to develop and deploy a novel taxonomy tool for analyzing cognitive, technical and team HPD during the provision of surgical care to understand how to improve safety and quality.

Methods:   A prospective multicenter study involving 3 adult affiliate hospitals (level 1 trauma center, quaternary care university hospital and a VA hospital) at a large academic medical center was conducted over a 6-month interval in 2018.  An HPD tool was developed through systematic literature review according to PRISMA guidelines followed by Delphi consensus among medical error experts.  This tool classified HPD into 5 major categories related to cognitive, technical and team dynamic functions (Table).  Training of all surgeons in error taxonomy and categorization occurred thru an initial 2-week run-in period.  We then used the tool in weekly concurrent reporting of complications to categorize HPDs for all major adverse surgical outcomes across our 3 study site quality improvement conferences.  Surgeons self-assigned preliminary HPD classification to case complications, which were then adjudicated by a 3-person investigator panel following a service-wide case presentation and discussion.   

Results:  5365 cardiothoracic, surgical oncology, transplant, elective general surgery, acute care surgery, and vascular surgery cases were analyzed.  The overall major complication rate was 5% (188 complications).  Of these, 56% (n = 106) were HPD-related:  50% execution error, 31% cognitive dissonance, 13% communication error, 4% teamwork error, and 5% rules violation. The average number of HPDs per case was 1.8 ± 0.9. The frequency and distribution of HPDs was similar across sites, with cognitive bias in decision of care being most common (HPD Class IA.3) subtype, followed by recognition error (HPD Class IIA). HPD most commonly occurred postoperatively (58%), followed by intraoperatively (32%) and preoperatively (10%).

Conclusion:  HPD was identified in over half the instances of major surgical complications at a major academic medical center, most typically related to cognitive dissonance and execution of care. The prevalence of these HPDs suggests opportunity for enhanced education and training to reduce the incidence of HPD contributing to adverse outcomes.    The newly developed taxonomy provides a framework to facilitate quality improvement in understanding human error in surgery.

 

31.10 Variability Between Lateral and Anterior-Posterior (AP) Sacral Ratios in Anorectal Malformations

Posted on January 31, 2019

H. Ahmad1, D. R. Halleran1, A. Akers1, V. Alexander1, M. Levitt1, R. J. Wood1  1Nationwide Childrens Hospital,Center For Colorectal And Pelvic Reconstruction,Columbus, OH, USA

Introduction: The sacral ratio (SR) has been used as a tool to evaluate sacral development in patients with anorectal malformations (ARM) and to help (along with the type of ARM and spinal status) to predict future bowel control. Although the ratio can be calculated using images from either the AP or lateral planes, lateral images are believed to produce more reliable ratios, given that the calculation is not influenced by the tilt of the pelvis. The congruency of the sacral ratio in the AP and lateral planes has not been previously investigated. We therefore aimed to assess the variability in the AP and lateral sacral images.

Methods: We reviewed all patients with ARM treated at our institution  between 2014 and 2018 who had both an AP and lateral image of their sacrum. The SR was calculated using the ratio of the distance from the sacroiliac joint to the tip of the coccyx to the distance from the top of the iliac crest to the sacroiliac joint. All ratios were calculated by a pediatric radiologist. Variation between the SRs as determined by the AP and lateral images were compared across all patients and by ARM type using sacral ratio categories (0-0.39, 0.40-0.69, >0.70)  that were developed for the purpose of counseling families.

Results: 561 patients were included in the study. SRs in the AP plane varied by an average of 17% (IQR 4,25, range 0-154). The AP SR overestimated the lateral SR in 23% (N=128) and underestimated the lateral SR in 63% (N=354) of patients. The variability in measurements decreased with increasing sacral development, as patients with a severe hypodevelopment (SR <0.4, N=39) demonstrated a variation of 27%, patients with moderate hypodevelopment (SR 0.4-0.69, N=193) demonstrated a variation of 18%, and patients with normal sacral development (SR >0.7, N=329) demonstrated a variation of 15%. The difference in these groups was statistically significant (p=0.03).

Conclusion: The SR determined by images in the AP plane varied significantly from that measured using lateral images. These results demonstrate that the AP sacral ratio can lead to a significant misinterpretation of the degree of sacral development which would impair the ability to accurately counsel families on their child’s future continence potential. Based on these data, we recommend the lateral SR to be used as the preferred measure. The AP view remains valuable to assess for hemisacrum. 

 

31.09 Predicting Crohn's Disease Surgery Complications: Harvey Bradshaw Index vs ACS NSQIP Risk Calculator

Posted on January 31, 2019

K. R. McMahon1, C. Cordero-Caballero1, A. Afzali3, S. Husain2  1The Ohio State University Wexner Medical Center,College Of Medicine,Columbus, OHIO, USA 2The Ohio State University Wexner Medical Center,Division Of Colon & Rectal Surgery,Columbus, OHIO, USA 3The Ohio State University Wexner Medical Center,Division Of Gastroenterology, Hepatology, And Nutrition,COLUMBUS, OHIO, USA

Introduction: Gastroenterologists commonly use the Harvey-Bradshaw Index (HBI) to assess the severity of Crohn’s disease (CD) and to guide medical therapy. Surgeons, on the other hand, often use the ACS NSQIP Surgical Risk Calculator to determine surgical risk when treating patients with CD. However, the ACS NSQIP calculator does not account for CD as a risk factor even though it has been shown to be an independent predictor of poor postoperative outcomes. The utility of the HBI to predict surgical complications has not been studied. The aim of our study was to compare the ability of HBI and ACS NSQIP Surgical Risk Calculator to predict surgical complications in patients with Crohn’s disease. We hypothesized that HBI is a superior method of predicting surgical complications in this patient population.

Methods: A retrospective chart review was done to identify patients who underwent surgery for CD and the post-operative complications. Patients who had an HBI calculated prior to, but within one month of surgery, were identified. The ACS NSQIP Surgical Risk Calculator was used to calculate each patient's predicted risk. The group was divided into high and low risk based on the calculator’s listed probability for any complication. Patients were also divided into a low disease activity and high disease activity based on their HBI. Fisher’s exact test, unpaired t-test, and chi-square distribution were used for statistical analysis.

Results: 

A total of 61 patients were included. The average age was 37 years old. 40% were male and 60% female. The overall complication rate was 33%.

There was no significant difference between the high disease activity and low disease activity HBI groups in age, gender, ASA class, steroid use, or NSQIP calculated risk of any complication. There was no significant difference between the NSQIP calculated high and low-risk groups in age, gender, steroid use, or HBI. The higher risk group did correspond to a higher ASA class; this relationship achieved statistical significance (p=0.0113).

The high disease activity HBI group had significantly more surgical complications than the low disease activity group. Additionally, the high disease activity group also had a significantly longer length of hospital stay (table 1). There was no significant difference between the NSQIP calculated high and low-risk groups for surgical complications or length of hospital stay (table 1).     

Conclusion: HBI score appears to be a better predictor of postoperative outcomes than the commonly used ACS NSQIP Surgical Risk Calculator. Further study is needed to examine the relationship between HBI and surgical risk prospectively and in a larger population of patients.   
 

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